Bob Atkins, PhD, RN, FAAN went to nursing school in the 1990s, his mother went to nursing school in the 1960s, and he is Executive Vice Dean at the Johns Hopkins School of Nursing today.
In all that time, nursing education has changed very little. For example, even though nursing care is increasingly provided outside of hospitals, nursing clinicals for entry-level students still reflect the focus of the early 20th century hospital-based nursing program: preparing nurses to deliver care in hospitals. That creates some operational and programmatic challenges.
For one, hospital-based clinical placements and clinical faculty are scarce resources, which limits the number of students schools of nursing can accept and enroll into nursing programs. It’s an unnecessary challenge in the middle of a nursing shortage. Furthermore, today’s hospitals are increasingly emergency and acute care centers—even patients undergoing surgery frequently go home the same day. To prepare nurses to change the world tomorrow, we will focus on real-world nursing today, and that means enlarging the experience pipeline to include outpatient clinics, schools, hospice facilities, and even virtual reality.
“We’re trying to prepare practice-ready nurses for as many diverse nursing roles as possible.”
Robert Akins, PhD, RN, FAAN
The OUTside track
A new track in the MSN (Entry Into Nursing) program is expanding the pipeline to practice, preparing students for RN licensure through clinicals conducted entirely outside of the hospital setting.
It’s a fundamental change in how we prepare nurses. Students meet the same course objectives as their peers who train in inpatient settings, but conduct clinicals in outpatient settings providing care to people with congestive heart failure, wound care, and end of life care. The approach addresses the gaps in traditional nursing education and equips graduates to be practice ready by graduation, in whatever setting they choose.
How it works:
The pilot includes seven students who started their clinical rotations in spring 2024. They were selected for the program through a competitive application process, then assigned to a different clinical placement and paired one-on-one with a preceptor on site. The approach is doubly beneficial; in contrast to traditional clinicals, students are paired with a nurse already employed on site, so the program is sustainable. Then, students are precepted one-on-one inteaad of the 1-to8 ratio in hospital setting. They find the individual attention particularly valuable as they develop competencies in prioritizing care, documenting and providing clinical care.
“A traditional group clinical environment can be more competitive,” says student Nneka Utah. “If you’re not a particularly outspoken person, it’s easy to get lost in the crowd. One-on-one, all eyes are on you.”
“We’re able to compare our experiences and learn from each other, too,” she continues. All seven students attend their individual clinicals on Tuesdays, and afterward gather with Lindsay Muratore, DNP, FNP-BC, OCN, their shared clinical instructor, to debrief. Paired one-on-one with their preceptors, they have significant hands on experience to share.
Real-world impact
With more clinical time spent delivering care, students in the OUTside track are making an impact right away. Student India Grant was able to intervene and conduct a health assessment, ultimately identifying the correct cause of a new challenge: falls.
“I attended clinicals at a mental health facility,” India says. “Our patient recently started having falls, and others on the care team wanted to change her medicine. I intervened, checked the person’s feet, identified bruises and cuts, and found out she also had diabetes. We were able to intervene appropriately with diabetic foot care rather than changing this person’s psychiatric medication.”
Bennetta Thomas had a rotation in hospice care. “I listened to music with an older woman, massaged her feet, and was able to ease her experience at the end of her life,” Bennetta says. “I was also able to advocate for travel support so her family could visit.”
Nneka Utah created a flyer during her elder care rotation teaching older adults how to stay cool and avoid heat stroke during the summer. “So many people came up to me, thanked me, and implemented the strategies I suggested,” she says.
Ready to practice anywhere
“We’re trying to prepare practice-ready nurses for as many diverse nursing roles as possible.” says Dr. Atkins, one of the architects of the MSN (Entry Into Nursing) program’s OUTside track. “The nation needs nurses to provide acute care both in hospitals and in the community.”
Already, four in 10 nurses work outside of the inpatient setting. The Johns Hopkins School of Nursing is trying to increase that number for the impact these nurses will have on the nation’s health. Studies have shown that clinical care only determines around 20 percent of a person’s health, while social determinants of health, things like where people live, work, their education and income, determine 50 to 80 percent of their health. Nurses are already the largest segment of the health care workforce; with more nurses in communities, in more places along the pipeline of care, we can intercede upstream—before health concerns become an inpatient problem.
Competency-based education
The OUTside Track is just one arm of the school’s push to redesign nursing education in alignment with the current and future needs of health and the health care system. It’s important to expand the clinical pipeline, and clinicals remain a vital component of nursing education, accounting for around 1,000 hours of pre-licensure student education, but they are a ‘black box.’
“We can’t be sure what students will encounter, or how their clinical experiences contribute to the development of their competency and practice readiness,” says Dr. Atkins.
In addition to the OUTside Track, we’re implementing new, high-fidelity simulations using virtual and augmented reality. It all falls under the umbrella of “competency-based education,” an approach that enables students to understand up front the core competencies they need to master to be a successful nurse, and then practice the skills until proficiency.
“We have to ask ‘why are we doing it this way?” says Dr. Atkins. “And then be prepared to reimagine nursing education to train a larger and even more prepared generation of nurses that contributes to a healthier, more resilient nation.”